Complications of a coastal colombian life

I sit in the local airport lounge. In front of me are a mixture of cacti and palms and a stray tropical bird; around me is the cacophany of the many accents that make up this complex country of Colombia. The local lilting truncated coastal Guajiro, the crisp classical inland Paisa, and the wail of the ubiquitous under-two year old child all fill my ears. 

Two months have already flown by since I walked past these airport palms to a first look at my new home, Riohacha. Hot, sometimes dry sometimes humid, full of color and life, and very very noisy, Riohacha mixes all the components that make up this mysterious in your face but try to understand us if you can region of La Guajira. Every color of skin, every type of hair and clarity of eye, and a mix of Afro-Colombian, indigenous Wayuu, Dutch ancestry, Lebanese, Palestinian, and Jordanian third-generation immigrants, Wiwa, Kogui, and perhaps even Arhuaco cultures that migrate from the western mountains of the Sierra Nevada and further, and Colombian expats working in the oil and mining industries living with one foot in Bogotá and one in Riohacha all make up this precariously positioned seat of the state of Guajira. 

I arrived with simplified expectations and found complicated impressions. Instead of desert I found a semi-arid mix of sand, mud, and lakes with flamingoes and cactus, seaside and dried up cracked earth located within a short circumference; where I expected villages with malnourished children but also with innovative uses of local resources, I found scattered indigenous communities dependent on handouts and in a process of losing their farming and water-tending traditions. It appears that the only expectations that were matched in impressions were the excellence and commitment of my work colleagues and the widespread corruption and brokenness of the health system within which they operate. 

Colombia contains an incredible diversity of cultures and sub-cultures; however, here in Riohacha, a repeat track of the locally-derived various rhythms of Vallenato plays without ceasing. The majority of Riohachans live life outside their tiled or concrete patios which give way to an open concept house with small kitchen and large courtyard if they are rich enough. The key to status seems to be not fancy cars but the size of the family speaker and the force with which it vibrates the neighbors' beds until 5 in the morning. Much like in Cairo, life starts early and ends early; to cope with the heat many start their day at 5 or 6am and work from 7 until noon when they return home and join their children returned from school for lunch and a siesta until 2pm when they return to work until 6pm. My days vary due to the large span of land we travel and work in and can last from 6 to 13 hours usually with a nap caught as our truck bumps over muddy trenches and navigates hardened sand to the detriment of our long-suffering spines. 

With two months of experience in this complicated place, I have started to become used to hot temperatures, the bumpy car rides, and the exhausting nature of our work. I have stopped becoming surprised by Masses at which people clap after the Gospel and dance to the entrance song. I have yet to get used to the near constant loud loud loud music banging through my walls, the need for parties to have their speakers blasted until one can't even think let alone dance, and the ubiquitousness of large cockroaches. I hope to get used to the need to chat before getting down to business, the complete lack of personal space in lines, and the incredibly thick difficult accent of the region. I hope to find myself slowing down my walk, my pace of talk, and finding the time to call people "princess" and "queen" and "my beauty" as the locals do here. 

It has already been a swinging journey with an incredible diversity of experiences. If I persevere, I can be part of team that is bringing better care to those dispersed in forests of cactus and will see the lights of the region who are working to improve this troubled terroir. If I persevere, I will overcome becoming embittered by the corruption and egotistical attitudes which only bring it down. 

Here's to the next chapter in this complicated coastal life. 

Week Four Plus Malawi

Exhausted. Here are some random vignettes:

Bring Your Problems to the Mzungu

legit:

Doctor, my leg is swollen. Bambo (father), you have fasciitis and need to go to the hospital. Okay, doctor, maybe next week. 

Hello, mother, does your child have diarrhea? Yes. Have you seen any worms in the stool? Yes, there is something in the placenta causing the pain. (I think that was a translator slip for umbilical cord??? What am I to think)

Server in a small restaurant

“Madam, I have a problem.”

My brother died late last year. He had an accident with a crocodile. Now his seven children are living with my parents and I want to take the children to private school. No, the public school is very far. No, it isn’t safe to walk. Their mother is there but I keep telling them the kids need good school and they don’t understand. I don’t know what to do. I make 9000 kwacha (less than $20 US) a month and am married with two kids to take care of. Yes, maybe I could bring one at a time here to Nsenje to go to the public school here. What can I do?“

Elderly woman on the porch in front of a general/grocery store

“Hungry, hungry!” 

Disheveled middle-aged man walking on the street

“Madam, hungry, madam, food?”

not so legit

children (almost always boys) on the street seeing “mzungu” or white people immediately shouting

“Mzungu, give me my money!” to which I always reply “that’s not nice to say!” even if they don’t understand

youngish ?intoxicated man of normal muscle bulk in front of the restaurant asking for food from the middle of the street by making hand to mouth motions. This was, by contrast, after I saw a skeletal young man pass by, emaciated, dazed, and did not stop him to at least assess his status a little more. AIDS, newly orphaned, homeless? Hard to tell in this post-flood craziness. 

Many here are fat, well nourished, well off from a nutritional standpoint. However after the recent floods, the camps are full of babies and children growing a new fuzz of the rust-colored hair of protein energy malnutrition, arm circumferences are shrinking, and bellies swelling.  Adults exhibit the dazed look of the anemic and come with frequent complaints of headache, fatigue, dizziness. Judging by nail bed color, most Malawians are anemic at baseline augmented by attacks of malaria which infects and destroys blood cells, and unrelieved by a traditionally iron-poor diet.

Nsima, a corn flour staple of the diet here, is likely the only food for some. Others in camps have received air drops and vanfuls of peas, corn flour, and soya pieces. Depending on whether the supplies come to them or are illegally sold by the foremen, what part of the shipment they receive, and what parasites and other diseases are adding to their energy requirements, some have just barely missed florid malnutrition. Micronutrient deficiencies clearly continue. It is hard to know also what the underlying nutritional status of most of the currently homeless was before they lost their kitchens, money, and their farmland. Theoretically, farmers, as are most here, have a greater variety of foods especially fruits and vegetables than their metropolitan compatriots, however most meals across the country consist of a bowl or plate of Nsima, a porridge like to solid mash of boiled corn flour and water that definitely takes the place as Malawi’s national food. Nsima for the better off fills half a plate while a small undernourished chicken leg or goat or beef stew and vegetables fill up a quarter each. Nsima alone, nsima pulled off in blobs and dipped in a stew, nsima with more water scooped up with a spoon, … nsima nsima nsima. Interestingly, the corn-fueled exhibit better stamina than the rice-fueled, according to one South African business man who noticed that he had to frequently feed his rice-eating employees in order to maintain their energy throughout the day. With the nutritional content of deer feed versus the amino acids of rice, this surprises my nutritional brain. From personal experience, nsima feels heavier and keeps the stomach full longer… head to head it contains as much protein and more iron (though plant iron is not very well absorbed) than rice and more of some vitamins. Brown rice or enriched rice are a different story. 

Greens of all kinds (mustard greens, rapeseed greens, collard greens, pea plant leaves…) are chopped and boiled and fancied up if possible with a helping of “groundnut” peanut flour. Boiled chopped cabbage, small green peppers, sauces of tomatoes and chili all make up some variety in the Malawian diet. Dessert seems to be a missing course but after a meal of 75-100% starch likely accompanied by a 35-45g sugar bottle of fanta or coke, who wants more sugar? 

Fried potatoes (chipsi), junk food, and juice appear to be the treats of choice. Interestingly despite the corn there is a relative dearth of variety in corn use. Nsima, porridge, roasted corn cobs (more street food than home food), corn oil, and popcorn make their way to homes however corn bread, cornflour breading for fried chicken, roasted corn, and cobs for the home cook never make it. 

Church

Amazingly, it is 4pm on a Sunday and in our quiet lodge, we are graced via loudspeaker transmission over the fields and small buildings over four hours of the raspy yelling of an impassioned preacher. Please stop. Catholic Mass this morning lasted over 2 hours with lots of singing from a young choreographed choir, young praise dancers in the front (dancing in unison no less), and multiple collections for each church of the parish. Another nondenominational pentecostal-like service I attended with a friend lasted over 4 hours of fervent if painfully voluminous speaker-aided praise and worship. Time seems to stand still and church services make up much the week if not the Sunday for the faithful. 

Walking into a church full of Africans in front of images of a sandy blond blue-eyed Jesus unnerves me. I want to shout to the whole congregation “Jesus was likely Aramaic and definitely Jewish!! His skin was darker than mine!” Clearly the Scottish/Irish influence of imperialism permeated the culture with a western Jesus. 

Of course not understanding more than three words also proves difficult. Even with the Mass somewhat memorized, I find it difficult to pray and gain spiritual nourishment. Fortunately Blantyre’s large expatriate population means English services available for the needy.

This week has been a blur of activity. The heat saps me from spilling out the details of my/our medical work. Today is a much needed day of rest (regardless of the raspy yelling of the scary preacher) and I’m determined to take some time to think not at all. 

At Bangula, the biggest camp of all

Flooded highway in Nsanje

Food delivery via helicopter/ World Food Programme

Walking back from Church

Nsanje market - notable for lots of dried fish

Week Four - Nsanje

7 am - preparation. Last minute packing. Breakfast. Get the taxi, return to the Lodge to pick up another traveler, drop her off, taxi, to the hospital to find my pediatric handbook, can’t find it, finally make it to destination: MSF Blantyre. 

9 am - why are they paying me? A quick briefing of the situation: MSF headquartered in Nsanje, a hard-hit southern province. Clinical teams going out as mobile clinics to the west bank and east bank. The east bank is flooded into two connected islands. 

10am - head out for Nsanje with a motley group of Italian photographer living in Cairo, Malawian coordinator, pharmacist, and health officers, Belgian flight coordinator, and Kenyan logistician. Stop for groceries, stop at the hospital again (light goes off) so I can buy a new handbook, stop for the bank, stop for photos, stop for more groceries, stop at a mobile clinic, for more photos, speed up when the Nsanje operations director calls wondering where we are. 

The mobile clinic is a van with two benches in the back and boxes of medicine. Well, previously stocked boxes of medicine. Now all remains are large amounts of well needed malarial parasite rapid tests all administered by an RN. Five of 35 people tested for malaria were positive at this smaller site. 

2pmish - Discovery Lodge. A run down (nice for the area) white conglomeration of low buildings boasts a bustle of MSF vans, MSF water containers, a meeting tent, kitchen tent, maps and computers huddled into one temp office, and electricians working desperately on the foregone electricity. After a brief briefing more for the photographer than any of the other four medical people, I bring out my coffee and oatmeal cookies while we shoot the breeze. The ops manager is from London ex 20 years ago and sounds more like a South African Malawian cross breed. He sports thick tawny locks, a matching tan, and a healthy dose of humour. The Kenyan speaks five languages including 3 buntu dialects, has worked mostly in Kenya and is not new to MSF. Outside of one other in the van we are all MSF newbies. In fact, as we gather together later perhaps only three are MSF seasoned. 

7pm - dusk has come, and we gather in between the two housing buildings for a daily meeting. Team leaders (a nurse leads a team of a clinician either MSF or department of health provided or both) x 2 describe their statistics and problems for the day. The health promotions leader urges again the need for mosquito nets, a problem which no other organization has stepped up to, and for proper installation of the nets. Child protection and social services are discussed, logistics chimes in with plans for a new office space in the former dining area, the engineers summarize their successes with reestablishing clean water through repaired and pumped out bore wells, and Alfred, the new chef, introduces himself to loud applause. 

As we gather and systematically share, including introductions of us (surprise, Suzanna, you’re actually going to work in the district hospital, not the mobile clinics or the helicopter-accessible pseudo-islands), the moon fades into existence from behind a sheer veil of misty clouds and the light fades into puffy clouds. The stars fall down in front of us - or is it lightning bugs that have curiously flown amongst us? Not to be outdone, one enlarging cloud advances from a distance with brilliantly silent lightning. As darkness falls, I feel a sense of peace. Work will be hard and perhaps problems not all solved, but here one finds the earth talking back. 

The situation here remains extreme. Many still without mosquito nets, clean water, sufficient food, medical attention, and many at risk of losing their temporary crammed shelters of standing Churches and Schools. Pride runs deep and fertile land calls strongly. Many resist moving to higher ground even temporarily for fear of losing their land when the waters recede. The waters receded then began to rise again. Camps swell instead of slim. This is a true natural disaster. 

After a delicious dinner of goat, rice, and beans and package of three large boxes for the teams tomorrow, we settle down to an early bedtime. Soaking wet again despite two showers, the air still, and the window lit by dramatic displays of frequent lightning, I find myself loathe to sleep. The lightning intensifies into a grand show of flashing power accompanied by frequent thunder. Out of nowhere, a very spooky melody in minor loops over and over again. Have I landed in a horror film? Is this real? Will we sleep enough to work the next day? Perhaps we will drift off to a land of ice and snow, perhaps the thunder will interpolate itself into our dreams as the roar of a rapids splashing cool against our faces and arms. Where we will navigate I know not. How we navigate the ultimate Physician knows. Lord, increase our work. Bless our minds, bodies, and hands. Ease the suffering of your people, and bring them comfort and peace. 

I have arrived. 

Week Three

She lay in bed, a different child, alert, alarmed, and blessedly full of life. I left Moyo house (the malnutrition ward where I work) dejected Friday after attempting to resuscitate this lethargic child spiralling slowly into respiratory failure. But with the appropriation of a CPAP machine from the special care ward and finally correcting her severely low potassium (my part) she survived. She survived!!! 

The past week brought me to a new level of acceptance. Finding a balance between acceptance and action proves difficult. Passivity and complete clinical detachment stops us from empathy. Over-involvement emotionally and constant frustration at the barrage of failures leads to burnout. Each without balance takes us away from caring properly for our patients. How do we find the middle ground, where we are empathetic, detached, and still proactive about correcting faults?  I find that the emotions of Malawians are less strongly expressed and that demeanors seem more flat. From the outside it would seem that the nurses and even some of the registrars don’t even care or don’t understand the importance of acting quickly with an ill child. Amazingly, the nurses are actually told not to cry. As in you are not allowed to cry. Ever.

Perhaps it is an overbalance towards detachment after the trauma of witnessing such high mortality rates. I can’t even imagine what the staff in the adult world feel, where mortality rapidly outstrips the pediatric world. Perhaps it is that most are completely overworked and underpaid. A visiting nurse from the UK working on training here shared with me that in an epiphanal moment, the nurses she was talking to finally told her that they simply don’t understand why they are doing. How can we expect someone to act quickly when they don’t understand what a sick child looks like or the difference between administering antibiotics to a child with meningitis (asap) versus to a child with an ear infection (needs to happen but not emergent)? A few of the older nurses are extremely good. They have a clinical acumen and an understanding of triaging work that would benefit their younger counterparts. Unfortunately sometimes they work alone in our ward for up to 20 patients. How can we expect them to be able to sustain an acceptable level of care without support? 

I learned also about the need to feel useful. As a “super-numerary” in my ward, perhaps my clinical attention is helpful to my patients, but I don’t have any confirmation that I can actually make some sort of lasting impact on the community I serve, no matter how small. 

Is it too much to expect to improve my environment? Is it right to only take (experience, however traumatic), and not be able to give in equal or greater measure?

Fortunately, the medical students rotate a week through our ward on their six-week pediatrics rotation, so I have had the opportunity to corral them into a more thorough orientation to our ward and some teaching on malnutrition as well as basic gastroenterology (intestinal medicine) topics. The students surprised me with their interest and their answers, especially one in particular who went levels deeper into the mechanisms of immune suppression in malnutrition. Wow. In comparison, some of the students have difficulty even coming up with a differential for diarrhea (not hard). The students are the future, so filling them up with knowledge and the ability to analyze and problem solve will only improve the community within which we work. I will keep telling myself that, at least. 

Burnout seems a large problem for the physicians here as well. In a department staffed mostly by ex-patriates on either permanent or several year positions, the improvements in the individual wards move like the land: barren, fertile, then barren again. Changes made sometimes stick but often devolve as the spearheading leaders leave. Malawian staff seem to have little cost or moral incentive to stay in a hospital whose bulk swallows their efforts of reconstruction. From my limited perspective, I wonder if the medical system of this large public hospital will change much in the next ten years. I choose optimism. 

Taking a break

The hammock swung gently to the rhythm of the waves. Above me leaves fluttered their salutations to the wind, below me the grass grew soft and spongy. Cape McLear. 

To a person accustomed to dramatic ocean and yards of sand unspoilt by the frequent interruptions of aggressive vendors, Cape McLear may seem more trouble than its worth. As the weekend went by, though, I found myself lulled through the sunshine and the rhythmic strokes of my kayak through the blue green waters into a calm and peace of mind rarely felt in Blantyre. I went through it all that weekend: homesickness, frustration, fear, loneliness, pain physical and emotional, economic hardship (temporary and nothing compared to the real hardship around me), and ultimately, peace. Well at least until we left and drove in our rickety minibus through an incredibly scary storm on an unlit main road lined with soaked pedestrians who blended into the darkness.

Cape McLear gifted me with many memories. Kayaking through a grotto of metamorphic stones, finding that I was spied on by little gopher-like animals (rock hyrax) peeking through the rocks, holding the hands of many many beautiful children of the beach with their simple readiness to be loved, watching lights float slowly over the water as the fisherman went to their nighttime catches with four or five glass lanterns held by a bar over their hand hewn canoes, playing Bawu (like mankala) with local men who taught me and then playfully beat me. 

Sunday morning, trying to visit God’s house, I made my way into the small village behind the sand strewn shore. Roughly thatched houses perched awkwardly over unmarked plots of sandy land and chickens scratched for their mid morning snack under strings of drying laundry. After zig-zagging through the playing children and overly small pathways, the village opened up to a large stretch of farmland overlooked by the impressively formal and large building of a Catholic church. I walked in to one person. Hello, I heard there is Mass today, now, actually? Oh, no, the priest comes once a month. Mass was 7:30 am (two hours ago) in Monkey bay (half an hour away). Oh. We do have prayer services every week. In english? No, in chichewa (the national language in addition to English). Okay. 

I stayed through the 2 hour Chichewa service of prayer, songs, Bible readings, and multiple collections (not sure if each was for a different church but every collection basket was linked to a Saint’s name read aloud). As the narrow pews slowly filled, many came up to greet me, the one Muzungu (white person/foreigner). Surprisingly, men and women sat separately as they sang back and forth. A male leader would start followed by simple starkly beautiful harmonic response. The melodies were simple and repetitive enough that even I could join and could harmonize easily. At the end all the visitors were asked to come to the front to introduce themselves and where they are from I said a little anxiously in Chichewa in front of the whole smiling congregation “my name is Suzanna. Blantyre. Canada. Thank you very much.” 

My name is Suzanna, Blantyre, Canada, Texas.  Thank you, Cape McLear.